Breast Reconstruction

During the consultation, your doctor will talk to you about the changes that you would like to make in your appearance. He/she will explain the different options available to you, the procedure itself, and its risks and limitations. He/she will also explain the kind of anesthesia required, surgical facility used, and the costs involved.

Your doctor will begin with a complete medical history and may order tests to determine your fitness for surgery. Depending on your age and state of health, these tests could include an electrocardiograph (ECG), chest x-ray, spirometry (lung function test), and possibly a screening test for Hepatitis and HIV as well.

Take this opportunity to ask all the questions you have about the surgery, and ask to see photos of the doctor’s recent patients, before and after surgery. Also ask for, and follow up on, patient references. Learning everything you can about your options, risks and benefits is the key to making an informed decision. See Questions to ask your doctor below.

There are two major types of breast reconstruction: breast implants and flap reconstruction:

• Breast implants

  The most common breast reconstruction technique, implants are rubber shells filled with either silicone gel or a saline solution. Breast implants are typically inserted through the use of a tissue expander. In this technique, a silicone balloon or bag is surgically placed beneath the chest muscle. Through a valve buried under the skin, the surgeon injects a sterile saline solution into the bag, expanding it. The “expander” stays in place for several weeks or months, during which time weekly or twice-weekly injections are administered. Once the skin has expanded sufficiently, the bag is replaced with a permanent implant during a second surgery.

  A third surgery may be recommended to reconstruct the nipple and areola. In order to ensure proper placement of the nipple, this operation is normally performed at least three weeks after implant surgery, giving time for the new breast time to settle into its permanent position. The nipple is usually fashioned from a small piece of skin drawn from the breast mound. A separate skin graft forms the areola. About six weeks later, the nipple and areola will be colored to match the other side using a medical tattoo technique.

• Flap reconstruction

  This technique creates a new breast using a section of muscle, skin and fat taken from another area of the body. It requires a longer hospital stay and more recovery time than implant reconstruction, and it also leaves scars at both the breast site and the donor site. But because the new breast is made of natural tissue, it looks, feels and ages more like a normal breast -- which many patients prefer. In addition, the use of natural tissue eliminates the complications that can arise when foreign objects such as implants are inserted into the body. Flap reconstruction may also be recommended when the skin won’t expand enough to cover an implant.

  Flap reconstruction may be performed using a pedicle flap or a free flap. The pedicle flap allows the tissue used in reconstruction to remain attached to its original blood source. The tissue is moved to the breast area through a tunnel under the skin. In the free flap technique, the flap tissue is completely removed and reattached to the breast area, where its blood vessels are connected to those in the chest area through microsurgical techniques.

• Types of flap reconstruction:
  1. Transverse abdominus musculocutaneous flap
     The TRAM procedure can be performed as either a pedicle flap or a free flap. A section of muscle, fat and skin is surgically removed from the abdomen and used to form the new breast. Sometimes referred to as “tummy-tuck” reconstruction, this procedure flattens the stomach and reconstructs the breast simultaneously. After the surgery, the abdominal muscles are temporarily weakened, and in rare cases, this weakness becomes permanent. If you are considering future pregnancy, be sure to tell your doctor because this sort of abdominal weakness can affect future pregnancy.
  2. Latissimus Flap
     In this technique, a section of the latissimus dorsi (the back muscle arising from the top of the hip to the arm just below the shoulder) is removed to form a new breast. This tissue is often quite thin, so a small implant may be required as well.
  3. Other flaps
     If the abdominal or latissimus tissue is unsatisfactory, a flap can be taken from the upper, middle or lower part of the buttock. However, this technique tends to weaken the gluteal muscle, restricting an athletic patient’s activities. It also requires the surgical removal of a vein from one leg, since the gluteal blood vessels often aren’t long enough to stretch from the chest area to the armpit where they must be reattached. If all other methods are unsatisfactory, tissue can be taken from the upper hip or “love handle” area. This technique is usually a last resort, since this tissue does not lend itself well to shaping a breast. Taking a flap from this area can also leave the hips uneven.

After surgery you will be tired and sore for one to two weeks. Your doctor can prescribe pain medication to relieve any discomfort. You should also expect some swelling and bruising, which could last for several weeks. Some procedures require the insertion of a drain for at least a week to remove excess fluid from the surgical site. Your stitches will either dissolve or be removed within ten days of surgery.

For the first twenty-four to forty-eight hours after surgery, you can apply ice to the area every fifteen minutes to reduce pain and swelling. After a tissue expansion or implant procedure, you’ll be allowed to bathe again beginning twenty-four hours after the surgery. After flap surgeries, sponge baths are advised for about a week.

• In good physical health
• Psychologically stable
• Wanting to improve the appearance of their chest
• Well informed about the procedure
• Realistic about the outcome

The above is only a partial list of the criteria that your surgeon will consider in determining whether or not this procedure is appropriate for you. Be sure to ask your surgeon if he/she considers you an ideal candidate for breast reconstruction.

1. Which type of breast reconstruction is best for me?
2. Are the desired results I described realistic?
3. Where is the surgery performed? How long will the procedure take?
4. Are there other procedures that I should consider to enhance the affects of breast reconstruction?
5. What kind of anesthesia is used?
6. How much does it cost?
7. What is your experience in performing this procedure? (How long has he/she performed this procedure, and how many he/she has performed in the past year?)
8. What percentage of patients have had significant complications? (The physician should disclose this information to you.)
9. Will you repeat or correct the procedure if it does not meet agreed upon goals? And if the procedure must be repeated / corrected, will I be charged again? (The physician should provide you with his/her policy on this issue.)
10. May I see "before and after" photos of recent patients? (The physician should provide many photos of recent patients.)
11. May I have the names and contact information for several recent breast reconstruction patients? (Follow up to get first-hand information on the procedure and the surgeon.)
12. Could I observe the exact procedure I am considering before I decide to have the surgery? (Either on videotape or live.)
13. What should I expect post-operatively in terms of soreness, what to watch for, medication, bathing, and level of activity?
14. Who will be assisting during the surgery? What are their qualifications? (Does the plastic surgeon perform the entire surgery?)
15. Have you ever had your malpractice insurance coverage denied, revoked, suspended?
16. Do you offer patient financing?

• Tell your doctor about any allergies you have (to foods, drugs, environmental elements).
• Tell your doctor about all medications you are taking (both prescription and non-prescription)
• Avoid aspirin and aspirin-containing medicines, as well as anti-inflammatory medicines such as Nuprin, Motrin, and Advil for two weeks prior to surgery. Also avoid herbal remedies such as St. John’s Wort, gingko biloba, some types of Chinese black mushrooms and other natural medicines and foods that may thin the blood.
• Be sure to tell your doctor if you smoke. Smoking can lead to complications and poor healing.
• Carefully follow any instructions your doctor gives you regarding eating and drinking.
• Arrange for someone to drive you home after surgery.

The information on this web site is only intended as an introduction to this procedure and should not be used to determine whether you will have the procedure performed nor as a guarantee of the result. The best method of determining your options is to consult qualified surgeons who are able to answer specific questions related to your situation.

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